Provider Demographics
NPI:1215934849
Name:MEDIVAC CORP
Entity type:Organization
Organization Name:MEDIVAC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-755-3800
Mailing Address - Street 1:812 CYCLONE AVE
Mailing Address - Street 2:P.O. BOX 348
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537-1300
Mailing Address - Country:US
Mailing Address - Phone:712-755-3800
Mailing Address - Fax:712-755-7151
Practice Address - Street 1:812 CYCLONE AVE
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-1300
Practice Address - Country:US
Practice Address - Phone:712-755-3800
Practice Address - Fax:712-755-7151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28307003416L0300X
NE51053416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA16171OtherWELLMARK BCBS
IA0161711Medicaid
IA0161711Medicaid
NE=========00Medicaid